PrEP Pressure: A New Issue with Truvada In the Gay Community

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PrEP has helped usher in an era of unprecedented sexual liberation in the gay community — but it’s brought with it a new issue that needs to be talked about. Lighthouse Co-Founder Nick Fager weighs in.

Truvada (aka PrEP) is a revolutionary drug in HIV care and prevention which has rapidly changed our culture since it was approved by the FDA is 2012. We have quickly entered a drastically new era where people with undetectable HIV cannot transmit the virus sexually and PrEP is over 99 percent effective in preventing new infections.

These medical breakthroughs have helped our community to shed a lot of our fears and anxieties around sex while ushering in a new generation of sexual liberation in the gay community. Many clients have told me that PrEP has allowed them to actually enjoy sex for the first time without the constant worry.

However, there is one problematic issue that the PrEP revolution has brought about that I have consistently noticed in my work with the gay community. Men are being pressured to have unprotected sex more than ever, and often people are being put into situations where their values around sexual health are being compromised.

Here are the three types of Truvada pressure I’ve heard about from my clients.

Pressure to Go On Truvada, or PrEP

“All my friends are on PrEP. They keep looking at me when I say I’m not on it like, what? Why?”

Often, gay men get pressured by their friends and sexual partners (and sometimes doctors) to go on PrEP but feel conflicted about whether they want to go on a daily antiretroviral medication that they might not necessarily need. In an Instagram survey of over 750 respondents on my handle @GayTherapy, 36 percent of respondents who are not on PrEP say they feel pressure to go on PrEP. Of course not everyone has access to PrEP so choosing whether or not to go on PrEP is a privileged decision, but just because you have access to it doesn’t mean that it’s the right choice for you.

There are a number of reasons why PrEP doesn’t make sense for everyone. 10-30 percent of people experience side effects such as nausea, fatigue, and dizziness. Some individuals experience elevations in blood tests that look at kidney functions as a result of taking PrEP. We don’t have enough data to conclusively say that there are no long term side effects to taking PrEP, and there have been concerns that long term PrEP usage can lead to reduced kidney function and bone mineral density. PrEP requires visits to your doctor every three months which many people are not willing to do, and depending on your insurance coverage, PrEP may also be prohibitively expensive.

Finally, for many people I’ve seen in treatment, there is still fear and trauma from the AIDS crisis that makes taking Truvada a scary concept. Some people simply don’t feel comfortable trusting a relatively new drug with their sexual health.

At the end of the day, PrEP is not for everyone, and condoms are an extremely effective way to prevent not only HIV but other STIs as well. They have worked well for a long time in our community and there is nothing wrong with sticking with what you know.

Pressure to Have Bareback Sex Once You’re On PrEP

“But we’re both on PrEP, why do we need to use a condom?”

This question is one example of PrEP pressure, and a mild form of it in compared to many stories I’ve heard. When someone who is on PrEP requests a condom, it is usually not because they lack education about the effectiveness of PrEP, but rather because condoms make them feel safe and comfortable within that specific situation. In the same Instagram survey referenced above, 56 percent say they’ve been pressured to have bareback sex in the age of PrEP, despite preferring to use condoms.

There are a lot of reasons why someone on PrEP might want to still use condoms — i.e. protect from other STIs, PrEP not being 100 percent effective, they don’t trust that their partner is actually on PrEP consistently — but at the end of the day, the reason doesn’t really matter. This person is making a sexual health decision and they shouldn’t have to explain themselves, be second guessed, talked down to, or pressured.

Once someone says they want they want to have sex with condoms, the only answer is, “Okay.” Maybe condoms are a dealbreaker for you, and that’s okay too. Just don’t shame the person for making a sexual health decision or pressure them to change their mind.

Pressure To Have Lots of Sex When You’re On Truvada

“Now that I’m on PrEP, I feel obligated to be having sex all the time. It’s like I want to get my money’s worth or something.”

There is this common belief that if you’re taking PrEP daily, you better be having a lot of sex to justify it. And there are often corresponding slut-shaming judgments made about people that are on PrEP.

In reality, there is no minimum sex benchmark for going on PrEP. Many women go on birth control even though they are rarely having sex. It is a sexual health decision that makes them feel comfortable, and PrEP is the same. It’s not about frequency or number of partners, it’s about safety and comfort.

Try to acknowledge any “should” voices in your head when it comes to your sex life and challenge them. Sex is a want, not a should.

Creating a Culture That Fosters Both Liberation and Respect

Bareback sex is not the problem here. I think in certain contexts bareback sex while on PrEP can help people work through a lot of sex-related phobias and anxieties. The problem is the lack of respect for people’s boundaries and sexual health decisions that PrEP seems to have normalized.

PrEP pressure is a real thing that we need to be talking about, and it’s more important than ever to know what you are comfortable with sexually, how to lay down boundaries with others, and when to walk away if you’re being pressured or disrespected.

Maybe you’re on PrEP but still want to use condoms 100 percent of the time. Maybe you want to use condoms for the first few times until you build up a level of trust. Maybe you don’t want to go on PrEP at all. It is your decision and it is OKAY. If anyone pressures you otherwise, they are not the right partner for you.

PrEP has ushered in a new era of sexual liberation, but we have to couple that liberation with respect and inclusiveness in order to progress positively as a community. Everyone has different values when it comes to their sexual health and we need to respect those boundaries and never pressure anyone to do anything they’re not comfortable with.

For more content like this, follow Nick Fager on Instagram @gaytherapy.